Long-Term Disability Claim Is Denied? Know Your Rights

When a long-term disability forces you to leave your employment, you may be counting on your ERISA long-term disability insurance policy to cover important life expenses and keep your family afloat. When that claim is denied, it can create financial challenges and make you feel like you have been taken advantage of. Know your rights when a long-term disability claim is denied. Find out how you can use the ERISA rules to protect yourself, and your family, and get the benefits you need.

This blog post will expand on the overview of the 2018 ERISA rules for long-term disability benefits claim process with a particular focus on the new rights for claimants. It will explain what rights individuals have when their long-term disability claim is denied, and warn about common pitfalls to exercising those rights.

Last year, the Department of Labor issued new regulations for long-term disability insurance policies covered under the Employee Retirement Income Security Act of 1974 (ERISA). That includes most long-term insurance policies provided by public and private employers as a benefit to employment. These new rules expanded employee rights and help to ensure that those filing claims understand the process and what to do to receive the benefits they need. According to the new rules:

You Have the Right to an Impartial Decision Maker

Before the new rules took effect, the initial decision on whether to grant or deny your long-term disability claim could be made by someone with an interest in seeing the plan pay as little as possible. Now, employees have the right to have those decisions made by independent and impartial decision makers. This includes claims adjudicators (the ones making the decisions) and medical professionals reviewing your disability claims.

This is important because when people’s employment or compensation (including bonuses) depend on how likely they are to say no to long-term disability claims, your right to a fair decision suffers. By making your employer and its insurance provider use impartial decision makers throughout the process (instead of just on appeal), ERISA ensures you get a fair chance at your benefits.

You Have the Right to Know Why Your Claim was Denied

The new ERISA rules require the Plan Administrator to provide a clear explanation for why your long-term disability claim is denied. This includes:

What standards were used to deny the claim;

Why the claim adjudicator disagreed with your doctor or Social Security Administrator’s determination of disability (whether or not that was the reason for the denial);

What rules, guidelines, and standards are used to decide long-term claims;

The scientific basis for any denials based on medical necessity, experimental treatment, or other policy exclusions

This is important because before, when long-term insurance claims were denied, claimants were often left without key information that would allow them to understand how to obtain a different decision on appeal. By receiving a clear explanation for the specific reasons behind your denial, you and your long-term disability attorney can correct the errors before the window to submit new information closes after the appeal is finalized.

You Have the Right to Access Your Entire File in Time to Respond

Before the new rules took effect, your employer only had to provide you notice of your right to access your long-term disability claim file after it had made an “adverse benefits determination” — basically, when it said no to your claim. Now, you have the right to access your entire claim file, particularly when the insurance company develops new or additional evidence added in on appeal, before the final decision is made.

This is important because many long-term disability insurance claims are denied without claimants ever knowing what information is needed to prove their claim. By seeing what the decision-maker is relying on, you and your long-term disability attorney can review everything the claim adjudicator is using to make his or her decision, respond to the evidence, and provide additional information to support your disability claims. This is exceptionally important now that insurance companies have to share the opinions of non-examining file review doctors who they have hired to decide whether you are disabled. Now, you have the opportunity to respond to this evidence before the door gets closed on new evidence.

You Have the Right to Receive Notices In a Language You Understand (In Some Cases)

The new ERISA rules recognize that in some communities, business isn’t automatically done in English. If you live in a county where at least 10% of the population reads and speaks the same non-English language, it is up to your employer to send you notices in a language you understand.

This is important because non-English speakers often do not recognize the importance of notices sent only in English. If they don’t know they have received a notice of claim denial, it could cause them to miss filing deadlines to appeal the claim or file a lawsuit for wrongful denial of benefits.

You Have the Right to a Timely Decision

The rules requiring employers and insurance companies to give you a decision on your claim aren’t exactly new. But the 2018 ERISA rules make sure that decision makers can’t extend the process and get away with it. Once you submit your claim for benefits, your employer’s insurance provider only has 45 days to respond and can only request one 45-day extension. Appeals have the same 45-day time limit and extension. If you don’t get a timely response, your claim is “deemed denied” and you can proceed to court.

This is important because when you are disabled, long delays in the decision-making process can lead to debts piling up and cost you money in the form of late fees, penalties, and interest.

You Have a Right to Enforce Your Rights

One of the biggest changes under the 2018 ERISA rules is the expansion of an employee’s right to sue for adverse benefits determinations. Before the new rules, you could only sue an insurance company after your claim was denied, and then, only after you had exhausted all your administrative remedies. This could cause substantial delays and allowed insurance companies to cut off benefits or pay less than they should under the policy. The new rules expand the scope of employee benefits appeals and allows you to skip the administrative review process or any appeals if the insurance company doesn’t strictly adhere to the rules. If you or your representative ask for an explanation as to why the rules haven’t been followed, the insurance company or administrator must respond in 10 days. This may become a very powerful tool to keep claims on track.

The 2018 ERISA rules give employees whose long-term disability claims are denied more rights and stronger remedies. But you still have to work within those rules to get the relief you need. If you have received a notice of claim denial, or want to make sure your application for benefits is filed correctly the first time, the long-term disability attorneys at Bross & Frankel are here to help. We will review your denial and your condition, helping you protect your rights and your claim. Contact us for a complimentary consultation.